Immediate and 6-month follow-up results of coronary angioplasty for restenosis: analysis of factors predicting recurrent clinical restenosis

Re-angioplasty of in-stent restenosis versus balloon restenoses—a matched pair comparison

BACKGROUND

Despite different biological mechanisms involved in the restenotic process of in-stent restenosis and restenosis after balloon angioplasty alone, the occurrence of a second restenosis has been reported in the same range. There are no data available comparing the outcome after re-angioplasty of such lesions. We analyzed in a matched pair comparison the clinical outcome and angiographic long-term result of patients with balloon angioplasty of a first in-stent restenosis versus patients with balloon re-angioplasty of a first balloon restenosis.

METHODS

Both groups consisted of 74 lesions matched by treated vessel, lesion location differentiated in proximal and non-proximal, and angiographic appearance of coronary artery disease differentiated in singular stenosis, diffuse or mixed pattern. Clinical follow-up was 100%. Angiographic follow-up was 78.4% after median 174 days.

RESULTS

Angiographic restenosis rate in matched pairs of patients (n=46/74) was significantly higher in the balloon restenosis group (41.3%, n=19/46) compared to the in-stent restenosis group (21.7%, n=10/46, p<0.042). There was no death or myocardial infarction. After clinical follow-up, target lesion revascularization rate was significantly lower in the in-stent restenosis group compared to the balloon restenosis group (12.1%, n=9/74 versus 27.0%, n=20/74; difference between groups 14.9%, 95% confidence interval 2.0-27.3%, p<0.023). Multivariate logistic regression analysis revealed as predictors for a second restenosis unstable angina pectoris, non-proximal lesion, restenosis after balloon angioplasty and the occurrence of the first restenosis within 90 days after initial intervention.

CONCLUSION

Clinical and angiographic outcome after balloon angioplasty of a first in-stent restenosis was significantly better compared with balloon re-angioplasty of a first balloon restenosis.

Effect of gender on outcomes following renal artery stent placement for renovascular hypertension

To study the effect of gender on outcome following renal artery stent placement for renovascular hypertension, we prospectIvely followed 66 patients (30 males, 36 females) who underwent Palmaz stent placement in 89 renal arteries. There was no difference in the incidence of procedure-related complications between males and females. At 6-mo follow-up, the decrease in systolic (35 +/- 30 mm Hg and 27 +/- 25 mm Hg) and diastolic (15 +/- 23 mm Hg and 14 +/- 14 mm Hg) blood pressures was similar in female and male patients, respectIvely. Late follow-up at 19 +/- 11 mo also showed no difference in blood pressure response. In 44 patients who underwent repeat angiography at a mean duration of 9.1 +/- 5.6 mo after stent deployment, the incidence of restenosis was 26% in females and 24% in males (P = 0.85). We conclude that gender has no effect on the incidence of complications, blood pressure response, or angiographic restenosis in patients undergoing renal artery stent placement.

Restenosis following coronary angioplasty: clinical presentations and therapeutic options

Restenosis following angioplasty is an iatrogenic disease of increasing frequency. Restenosis may be defined in terms of either angiographic or clinical criteria. Definitions of angiographic restenosis have varied in different studies, accounting in part for the differences in reported restenosis rates. Most studies now define angiographic restenosis as either a > 50% loss of initial gain or an absolute lesion stenosis of > or = 50% at follow-up angiogram. Common clinical end points used in defining restenosis include recurrent angina, need for repeat revascularization, or myocardial infarction. Despite technical advances and multiple pharmacologic interventions, most studies have found that the incidence of angiographic restenosis remains in the range of 40%; in none of these studies, however, was complete angiographic follow-up obtained, and thus actual restenosis rates may be somewhat higher. In several studies, clinical restenosis has been found to occur in approximately 36-40% of patients. Thus, a minority of patients with angiographic restenosis have no clinical manifestations. Most patients who develop symptoms of restenosis develop these symptoms within the first 3 months after angioplasty. The presenting symptom in the majority of these patients is progressive exertional angina. Patients occasionally will present with unstable angina and only rarely with acute myocardial infarction. In patients who present with recurrent chest pain, several features have been found to be helpful in predicting whether they will have angiographic restenosis at follow-up angiography. Patients who present 1-6 months after angioplasty with typical anginal symptoms have a high likelihood of having angiographic restenosis. By contrast, patients who present more than 6 months after percutaneous transluminal coronary angioplasty with recurrent chest pain are more likely to have new, significant coronary lesions to account for their symptoms. Noninvasive testing in patients with clinical presentations suggestive of restenosis can, in general, add only modest information in predicting whether restenosis is indeed present. A negative exercise thallium test appears to have a high specificity in ruling out restenosis and may be helpful in patients who present with more atypical symptoms. Repeat angioplasty is the therapy most frequently utilized to treat restenosis, although coronary artery bypass surgery or medical therapy may be reasonable alternative therapies. Clinical success rates with repeat angioplasty are > 90%, and major complications are rare; however, restenosis will recur in a significant percentage of these patients. Some patients who develop such recurrent restenoses will ultimately benefit from a strategy of repeat angioplasties, although many will require surgical revascularization.